ADH PrepU Resp assigment
Which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia?
Irritability Clients who are experiencing hypoxia characteristically exhibit irritability, restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more pronounced, the client may become confused and combative. Coma is a late clinical manifestation of hypoxia. Apathy and depression are not symptoms of hypoxia.
A client with chronic obstructive pulmonary disease tells a nurse that he feels short of breath. The client's respiratory rate is 36 breaths/minute and the nurse auscultates diffuse wheezes. His arterial oxygen saturation is 84%. The nurse calls the assigned respiratory therapist to administer an ordered nebulizer treatment. The therapist says, "I have several more nebulizer treatments to do on the unit where I am now. As soon as I'm finished, I'll come and assess the client." The nurse's most appropriate action is to:
give the nebulizer treatment herself. The client's needs are preeminent, so the nurse should administer the nebulizer treatment immediately. The nurse can deal with the respiratory therapist's lack of response after the client's condition is stabilized. There is no need to involve the physician in personnel issues. Staying with the client is important, but it isn't a substitute for administering the needed bronchodilator. The order is for a nebulizer treatment not a metered-dose inhaler, so the nurse can't change the route without a new order from the physician.
A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction?
"I'll stay in isolation for 6 weeks." The client requires additional teaching if he states that he'll be in isolation for 6 weeks. The client needs to be in isolation for 2 weeks, not 6, while taking the tuberculosis drugs. After 2 weeks of antitubercular therapy, the client is no longer considered contagious. The client needs to receive the drugs for 9 months to a year. He'll be positive when tested and if he's sick or under some stress he could have a relapse of the disease.
A client with asthma asks the nurse if she should use her salmeterol inhaler when she exercises and experiences wheezing and shortness of breath. The nurse's best response is which of the following?
"No, this drug is a maintenance drug, not a rescue inhaler." Salmeterol is a beta2-agonist, a maintenance drug that the asthmatic client uses twice daily, every 12 hours. Albuterol is used as the "rescue inhaler" for bronchospasms. Salmeterol can be used to prevent exercise-induced bronchospasms, but it should be taken 30 to 60 minutes before exercise. If the client is taking salmeterol twice daily, it should not be used in additional doses before exercise; twice daily is the maximum dosage. Indications for salmeterol include only asthma and bronchospasm induced by chronic obstructive pulmonary disease.
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?
A client with a nasogastric tube Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.
At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer:
Albuterol The client is hypoxemic because of bronchoconstriction as evidenced by wheezes and a subnormal arterial oxygen saturation level. The client's greatest need is bronchodilation, which can be accomplished by administering bronchodilators. Albuterol is a beta2 adrenergic agonist, which causes dilation of the bronchioles. It's given by nebulization or metered-dose inhalation and may be given as often as every 30 to 60 minutes until relief is accomplished. Alprazolam is an anxiolytic and central nervous system depressant, which could suppress the client's breathing. Propranolol is contraindicated in a client who's wheezing because it's a beta2 adrenergic antagonist. Morphine is a respiratory center depressant and is contraindicated in this situation.
A client with a tracheostomy tube coughs and dislodges the tracheostomy tube. The nurse's first action should be to:
Attempt reinsertion of tracheostomy tube. The nurse's first action should be to attempt to replace the tracheostomy tube immediately so that the client's airway is reestablished. Although the nurse may also call for assistance, there should be no delay before attempting reinsertion of the tube. The client is placed in a supine position with the neck hyperextended to facilitate reentry of the tube. The obturator is inserted into the replacement tracheostomy tube to guide insertion and is then removed to allow passage of air through the tube.
The nurse is caring for an elderly, debilitated client who has been bedridden for an extended period. Which of the following indicates that the client has hypoxia?
Confusion The predominanat clinical finding in elderly or debilitated clients indicating that they have hypoxia is confusion. Fever, chills, productive cough and pleuritic chest pain could be indicative of respiratory track infection.
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?
Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Activities that help to prevent the occurrence of postoperative pneumonia are coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia.
The nurse should include which of the following instructions when developing a teaching plan for a client who is receiving isoniazid and rifampin for treatment of tuberculosis?
Do not consume alcohol Isoniazid/rifampin is a hepatotoxic drug. The client should be instructed not to consume alcohol during drug therapy. The drug should be taken on an empty stomach. If antacids are needed for gastrointestinal distress, they should be taken 1 hour before or 2 hours after the drug is administered. The client should not double the dose of the drug because of potential toxicity. The client taking the drug should avoid foods that are rich in tyramine, such as cheese and dairy products, or he may develop hypertension.
A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?
Elevate the head of the bed 30 to 45 degrees. Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The physician must be kept informed of changes in a client's status, but the priority in this case is alleviating the symptoms.
The nurse has completed an assessment on a client with chronic obstructive pulmonary disease (COPD). One hour later, the client has become confused and is not aware of his/her surroundings. Respirations are 34 breaths/min and cyanosis is noted around the lips. Oxygen saturation levels have decreased from 94% to 84%. Place the following nursing interventions in order of priority. Use all options.
Elevate the head of the bed. Start oxygen at 2.1 quarts (2 L) per nasal cannula. Call the rapid response team. Insert an intravenous line. Notify the family of the situation. The head of the bed would be elevated immediately to assist the client with lung expansion. Next, oxygen would be started. In this case, 2.1 quarts (2 L) would be initiated because the client has COPD. The rapid response team would be notified because the client might need intubation if his/her breathing and oxygen saturations do not improve. An intravenous line would be necessary for any administration of emergency medications. Notifying the family would be the lowest priority at this time. Stabilizing the client is the priority.
A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg (10.64 kPA); PaCO2, 65 mm Hg (8.64 kPA); HCO3-, 36 mEq/L (29 mmol/l). The nurse should assess the client for?
Flushed skin The high PaCO2 level causes flushing due to vasodilation. The client also becomes drowsy and lethargic because carbon dioxide has a depressant effect on the central nervous system. Cyanosis is a sign of hypoxia. Irritability and anxiety are not common with a PaCO2 level of 65 mm Hg (8.64 kPa) but are associated with hypoxia.
A client with pneumonia has a temperature of 102.6 ° F (39.2 ° C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care?
Frequent linen changes. Frequent linen changes are appropriate for this client because of the diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Position changes need to be done every 2 hours. Nasotracheal suctioning is not indicated with the client's productive cough. Frequent offering of a bedpan is not indicated by the data provided in this scenario. (less)
A client with tuberculosis is taking Isoniazid (INH). To help prevent development of peripheral neuropathies, the nurse should instruct the client to
INH competes for the available vitamin B6 in the body and leaves the client at risk for development of neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed. Following a low-cholesterol diet, getting extra rest, and avoiding excessive sun exposure will not prevent the development of peripheral neuropathies.
A client with chronic obstructive pulmonary disease is bedridden at home and gets little exercise. The nurse should assess the client for which of the following?
Increased calcium excretion. Prolonged inactivity causes the body to excrete excessive calcium. This leads to breakdown of bone tissue; as a result, the bones become brittle and fracture easily, a condition known as osteoporosis. The excessive calcium excretion that occurs during bed rest also predisposes the client to formation of renal calculi. Prolonged bed rest does not increase sodium retention, insulin use, or red blood cell production.
A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be:
Ineffective airway clearance. Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.
A nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?
It helps prevent early airway collapse. Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)
Which of the following is appropriate for a client with metabolic alkalosis?
Monitor serum potassium levels. With a client in metabolic alkalosis, the nurse should monitor for hypokalemia. Metabolic alkalosis can cause potassium to shift into the cells, resulting in a decrease of serum potassium. In metabolic alkalosis, the body tries to compensate by conserving carbon dioxide, so there is no need to have the client inhale carbon dioxide, as would be the case if hyperventilation were occurring. There is already a base bicarbonate excess with this condition, so the nurse should not administer sodium bicarbonate. Unless symptoms dictate, the client does not need to be placed on bed rest.
A client admitted with a deep vein thrombosis abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to improve these manifestations?
Nonrebreather mask A nonrebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.
Which of the following would be most important to teach a client older than 65 years to prevent a recurrence of bacterial pneumonia?
Obtain influenza and pneumococcal vaccines. Influenza and pneumococcal vaccines are effective in reducing the recurrence of pneumonia. Dietary changes are not indicated in the prevention of pneumonia. Antibiotics are ineffective against viral infections. Prophylactic antibiotic therapy is not typically prescribed because of the increasing prevalence of resistant bacterial strains.
Which of the following nursing interventions would best accomplish the goal of preventing atelectasis and pneumonia in a postoperative client?
Offer pain medication before having the client deep-breathe and use incentive spirometry. Deep-breathing exercises and use of incentive spirometry are more effective when pain is minimal. A client in severe pain tends to limit movement and to breathe shallowly to decrease the pain. Enough pain medication should be given to decrease pain without depressing respirations. Administration of oxygen or forcing fluids will not prevent atelectasis or pneumonia. Deep-breathing exercises and use of incentive spirometry should be done 10 times every hour while awake. The client's position should be changed every 1 to 2 hours to allow for full chest expansion. Ambulation, not just sitting in the chair, should be implemented as soon as physician approval is obtained.
While suctioning a client's laryngectomy tube, the nurse should insert the catheter
Until resistance is met, then withdraw it 0.4 to 0.8 inches (1 to 2 cm). The proper suctioning technique is to insert the suction catheter until resistance is met, withdraw the catheter 0.4 to 0.8 inches (1 to 2 cm), then begin applying intermittent suction while withdrawing the catheter. The suction catheter is inserted approximately 5 to 6 inches (12.7 to 15.2 cm). It is not necessary to insert the catheter as the client exhales. Coughing by a client does not necessarily indicate when to begin or stop suctioning.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
The system has an air leak. Constant bubbling in the water-seal chamber indicates a system air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.
For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?
Using a Venturi mask to deliver oxygen as ordered The client with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking 3 glasses of fluid daily wouldn't affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Clients with COPD and respiratory distress should be placed in high Fowler's position and shouldn't receive sedatives or other drugs that may further depress the respiratory center.
Which of the following symptoms is common in clients with active tuberculosis?
Weight loss. Tuberculosis typically produces anorexia and weight loss. Other signs and symptoms may include fatigue, low-grade fever, and night sweats. Increased appetite is not a symptom of tuberculosis; dyspnea on exertion and change in mental status are not common symptoms of tuberculosis.
A client is admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to find during a nursing assessment?
Wheezing, tachycardia, and restlessness Wheezing results when air is expired against resistance, such as from a collapsed airway. Tachycardia results fr(om hypoxia, and restlessness is a result of cerebral hypoxia. The client may be dyspneic but not bradycardic. A client may not exhibit a barrel chest. Hypotension, confusion, and weight gain are symptoms of heart failure.
A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for
atelectasis. In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.
A nurse is caring for a client who has end-stage chronic obstructive pulmonary disease receiving IV push morphine for pain management. During rounds, the nurse discusses with the physician the need to begin the client on a continuous morphine infusion. The nurse bases this request on
servicing as a client advocate is an important role. Being an advocate is a major factor in caring for clients. Adequate pain relief, particularly for those with terminal illnesses, falls under this concept. Euthanasia is the deliberate act of hastening death. Increasing morphine to relieve the client's pain would not be a deliberate attempt to hasten death. Living wills do not dictate the amount of medication a client may receive. Suctioning is important, but will not assist with pain relief.
A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the
skin test doesn't differentiate between active and dormant tuberculosis infection. The Mantoux test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the Mantoux test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?
• Administration of pain medications • Using the incentive spirometer • Frequent repositioning Activities that help to prevent the occurrence of postoperative pneumonia are coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia. The application of oxygen may increase oxygen levels and a treatment for pneumonia, but it will not prevent the infection from occurring.
A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung transplant. The nurse performs the initial physical assessment. Which signs and symptoms should the nurse expect to find?
• Dyspnea on exertion • Barrel chest • Clubbed fingers and toes Typical findings in clients with COPD include dyspnea on exertion, a barrel chest, and clubbed fingers and toes. Clients with COPD are usually tachypneic with a prolonged expiratory phase. Fever isn't associated with COPD unless an infection is also present.
A client is admitted with heart failure and pulmonary edema. To help alleviate respiratory distress, the nurse should perform which of the following actions? Select all that apply.
• Elevate head of bed to 90 degrees. • Administer diuretics as ordered. Elevating the head of the bed allows maximum lung expansion because gravity reduces the pressure of the abdominal viscera on the diaphragm and lungs. Diuretics are administered to a client with heart failure and pulmonary edema to decrease the fluid buildup in the lungs and decrease the workload of the heart. Placing a pillow under the legs would not correct shortness of breath. The client could not tolerate a position for postural drainage based on the current respiratory status.
A client is transported to the emergency department with an acute respiratory infection. Vital signs are T 102 F (38.8 C), P 110 bpm, R 32 breaths/min. Circumoral cyanosis is noted, and the oxygen saturation is 86%. What should be the immediate actions by the nurse caring for this client? Select all that apply.
• Initiate oxygen at 6 L/min via nasal cannula. • Place the client in high Fowler's position. The immediate needs of this client are oxygenation. Due to the cyanosis and decreased oxygen saturation, placing the client in high Fowler's and initiating oxygen will immediately improve gas exchange. Encouraging deep breathing and coughing, and maintaining in a side-lying position, will not improve breathing and will exacerbate the situation. Pursed-lip breathing would be appropriate for a client with COPD.
The client with chronic obstructive pulmonary disease (COPD) is taking theophylline. The nurse should instruct the client to report which of the following signs of theophylline toxicity?
• Nausea • Vomiting • Seizures • Insomnia The therapeutic range for serum theophyilline is 10 to 20 ug/mL (55.5 to 111 µmol/L). At higher levels the client will experience signs of toxicity such as nausea, vomiting, seizure, and insomnia. The nurse should instruct the client to report these signs and to keep appointments to have theophyilline blood levels monitored. If the theophylline level is below the therapeutic range, the client may be at risk for more frequent exacerbations of the disease. (less)
A client who has asthma is taking albuterol to treat bronchospasms. The nurse should assess the client for which of the following adverse effects that can occur as a result of taking this drug?
• Nausea. • Headache. • Nervousness. Albuterol is a beta-adrenergic agonist. Possible adverse effects include nausea, headache, and nervousness as well as insomnia and vomiting. Constipation is not associated with this drug. The client will not become lethargic; instead, he may experience restlessness.
The nurse is caring for an elderly client with a possible diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the nursing assistant?
• Obtaining vital signs. • Applying antiembolic stockings. • Keeping the client oriented. It is appropriate for the nurse to delegate obtaining vital signs and applying antiembolic stockings to the nursing assistant. The nursing assistant can also help keep the client oriented to time, person, and place by talking with the client. The registered nurse is responsible for evaluating the quality and character of the client's vital signs, but the assistant may take the vital signs and report readings to the nurse. It is the registered nurse's responsibility to assess the client's need for oxygen therapy and apply as needed in accordance with physician's orders. It is also the registered nurse's responsibility to perform the nursing history and assess the client's breath sounds.
The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. Which of the following steps should be included?
• Splint or support the incision to promote maximal comfort. • Inhale slowly through the nostrils; exhale through pursed lips. • Hold the breath for about 5 seconds to expand the alveoli. • Repeat this breathing method 5 to 10 times hourly. Splinting the incision is important to avoid stress on the surgical site and to promote comfort so that the client will adhere to the plan of care. Inhaling and exhaling are important to bring in adequate oxygen and clear out carbon dioxide; however, closing one nostril when inhaling would be inappropriate and ineffective. The most important step is asking the client to hold the inhaled breath for about 5 seconds, which keeps the alveoli expanded. This step should be stressed the most. Repeating the exercise 5 to 10 times hourly is the second most important point to emphasize in this teaching plan.